170 Br J Sports Med 2001;35:170–173

The acute phase response and exercise: court and Br J Sports Med: first published as 10.1136/bjsm.35.3.170 on 1 June 2001. Downloaded from field sports

K E Fallon, S K Fallon, T Boston

Abstract capacity, and transferrin, and transferrin satu- Objective—To determine the presence or ration.45 absence of an acute phase response after A number of studies have documented training for court and field sports. aspects of the acute phase response after exer- Participants—All members of the Aus- cise of a duration that would be expected to tralian women’s soccer team (n = 18) and induce significant damage to skeletal 6–12 all members of the Australian Institute of muscle. No data are available on the acute Sport netball team (n = 14). phase response in relation to court and field Methods—Twelve acute phase reactants sports. (white blood cell count, neutrophil count, Documentation of the extent and nature of platelet count, serum iron, ferritin, and the acute phase response to various types of transferrin, percentage transferrin satu- exercise is important, as changes related to the response may need to be taken into account for ration, á1 antitrypsin, caeruloplasmin, á2 acid glycoprotein, C reactive protein, and interpretation of haematological and biochemi- erythrocyte sedimentation rate) were cal measurements made during and after participation in sport. measured during a rest period and after The aim of this prospective study was there- moderate and heavy training weeks in fore to determine the presence or absence of members of elite netball and women’s the acute phase response in sports representa- soccer teams. tive of a wide range of field and court sports. Results—Responses consistent with an acute phase response were found in five of 24 tests in the soccer players, and in three Methods of 24 tests in the netball players. Re- All procedures conformed to the National sponses in the opposite direction were Health and Medical Research Council guide- found in seven of 24 tests in the soccer lines for experimentation with human subjects players and two of 24 tests in the netball- and all subjects gave their written informed ers. The most sensitive reactant consent before participation in the study. measured, C reactive protein, did not The subjects were all members of the http://bjsm.bmj.com/ respond in a manner typical of an acute Australian women’s soccer team (n = 18) or the phase response. Australian Institute of Sport netball team (n = Conclusion—An acute phase response 14). As it is diYcult to assess elite athletes in an does not seem to occur as a consequence absolutely rested condition, the pretraining of the levels of training typical of elite blood sample was taken from the netball group female netball and soccer teams. This has on their return from summer vacation before implications for the interpretation of bio- they started routine training, and from the soc- chemical variables in these groups. cer group after they had taken a two week break on September 28, 2021 by guest. Protected copyright. (Br J Sports Med 2001;35:170–173) from routine training. The second soccer sam- ple was taken after five months of training dur- Keywords: acute phase response; iron; plasma proteins; ing a week selected by the coach as a moderate inflammation training week, and the third sample was taken nine months from baseline after a week selected by the coach as a heavy training week. Department of Sports The acute phase response is a common The second netball sample was taken after five Medicine, Australian reaction to a range of threats to homoeostasis Institute of Sport, months of training during a week selected by including bacterial infection, surgery, burns, the coach as a hard training week, and the third Belconnen, ACT, neoplasia, tissue infarction, inflammatory dis- Australia 1 2 sample was taken nine months from baseline K E Fallon eases, and prolonged exercise. The response after a week selected by the coach as a moder- S K Fallon includes metabolic changes such as negative ate training week. Duration and type of training nitrogen balance, changes in lipid metabolism, in each of the seven days before blood Department of alterations in serum concentrations of cations, Physiology collection was determined by athlete question- T Boston changes in iron metabolism, leucocytosis, com- naire and review of coaching records. plement activation, and increases in proteins Soccer training consisted of running, cy- Correspondence to: primarily produced in the liver.3 Concentra- cling, weight training, and training on the soc- Associate Professor Fallon, tions of albumin, transthyretin, á fetoprotein, Department of Sports cer pitch. In the week considered to be moder- Medicine, Australian á2 acid glycoprotein, and transferrin decrease ate training, mean duration of training was Institute of Sport, PO Box during the response. Changes related to iron 12.9 hours, and, in the intense training week, it 176, Belconnen, ACT 2616, metabolism also occur, including increased tis- was 9.3 hours. Netball training consisted of Australia sue storage iron (increased serum ferritin) and weight training, court work, and practice Accepted 29 January 2001 decreased serum iron, total iron binding games. In the week considered to be moderate

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Table 1 Subject characteristics Serum iron, transferrin, ferritin, total iron Br J Sports Med: first published as 10.1136/bjsm.35.3.170 on 1 June 2001. Downloaded from binding capacity, percentage transferrin satura- Netball Soccer tion, creatine kinase activity, and haptoglobin Age (years) 18.4 (0.8) 23.0 (5.0) were measured on a Hitachi 911 analyser using Height (cm) 179.5 (7.1) 167.7 (7.9) Boehringer-Mannheim reagents. C reactive Weight (kg) 70.7 (10.6) 61.9 (7.1) protein, á1 antitrypsin, and á2 acid glycoprotein Values are means (SD). were measured by nephelometry on a Beck- mann Array Protein System (Beckmann, Brea, California, USA) using Beckmann reagents. training, mean duration of training was 10.5 Erythrocyte sedimentation rate (ESR) was hours, and, in the intense training week, it was measured using standard manual methods. 10.3 hours. All dependent variables were analysed using Exclusion criteria included the presence of a two tailed Student’s t test for diVerences from an acute or chronic inflammatory disease, resting levels. Statistical analysis was per- infection, or injury and use of anti- formed using Statistica, version 5.1 (StatSoft inflammatory medication or supplements con- Inc, Tulsa, Arizona, USA). taining iron. On three occasions, 20 ml blood was drawn Results from an antecubital vein, using a sterile Table 1 shows the characteristics of the technique, immediately after the subject had subjects. laid down. Samples were immediately trans- In the soccer group, 13 subjects reported no ferred to a laboratory adjacent to the blood training in the 72 hours before the start of the study, three had trained lightly up to 48 hours collection area and were processed within 60 before the start, and two had trained lightly minutes. All samples were obtained between 8 within 48 hours of the baseline measurements. am and 9 am. In the netball group, no subject had performed Table 2 Acute phase reactants in netball players any training within 72 hours of baseline meas- urements. In this group, mean (SD) total train- Variable Resting Heavy training Moderate training ing time during the week before baseline was 3 White cell count (× 109/l) 6.37 (1.23) 6.64 (1.10) 7.38 (1.26) (0.6) hours. Table 2 summarises the findings Neutrophil count (× 109/l) 3.22 (0.68) 3.30 (0.75) 3.98 (1.22) for acute phase reactants in the netball players. Platelet count (× 109/l) 217 (36) 229 (57) 229 (56) ESR had decreased after both heavy and mod- ESR (mm/1st h) 12 (6) 6.6 (3.8)* 8.1 (4.7)* C reactive protein (mg/l) 2.33 (1.21) 2.52 (0.68) 1.66 (0.89) erate training weeks. Serum caeruloplasmin Caeruloplasmin (g/l) 0.441 (0.154) 0.521 (0.172) 0.545 (0.179)* and á1 antitrypsin had increased after the mod- á1 antitrypsin (g/l) 1.65 (0.36) 1.83 (0.31) 1.85 (0.29)* erate training week. á acid glycoprotein (mg/dl) 82.9 (17.4) 89.8 (21.0) 99.2 (31.2) 2 Table 3 summarises the findings for iron Values are means (SD). related variables and creatine kinase activity in *p<0.05 v resting (two tailed Student’s t test). the netball players. No significant changes were ESR, Erythrocyte sedimentation rate. found in these variables. http://bjsm.bmj.com/ Table 3 Iron related variables and creatine kinase activity in netball players Table 4 gives the findings for acute phase reactants in the female soccer players. After the Variable Resting Heavy training Moderate training heavy training week, white cell count had

Iron (mmol/l) 16.9 (6.6) 18.8 (6.3) 19.8 (7.8) decreased and á1 antitrypsin had increased, Ferritin (ng/ml) 53.6 (39.7) 42.9 (28.8) 38.2 (26.1) and after the moderate training week, signifi- Transferrin (g/l) 3.19 (0.53) 3.54 (0.53) 3.78 (0.47) Transferrin satn (%) 24 (10) 24 (9) 23 (10) cant decreases were found in the white cell Creatine kinase (U/l) 180 (132) 208 (90) 145 (69) count, neutrophil count, platelet count, C on September 28, 2021 by guest. Protected copyright. reactive protein, caeruloplasmin, and á2 acid Values are means (SD). glycoprotein. Table 4 Acute phase reactants in women soccer players Table 5 summarises the findings for iron related variables and creatine kinase activity in Variable Resting Moderate training Heavy training the female soccer players. Serum iron and per- White cell count (× 109/l) 7.49 (2.50) 5.96 (1.47)* 5.88 (1.57)* centage transferrin saturation were decreased Neutrophil count (× 109/l) 4.28 (1.84) 3.46 (1.04) 3.05 (0.94)* after both the moderate and heavy training Platelet count (× 109/l) 248 (41) 242 (37) 226 (46)* ESR (mm/1st h) 9 (5) 9 (7) 9 (4) weeks. C reactive protein (mg/l) 2.68 (1.70) 2.48 (1.72) 1.62 (1.32)* Caeruloplasmin (g/l) 0.48 (0.14) 0.47 (0.13) 0.44 (0.15)* Discussion á1 antitrypsin (g/l) 1.86 (0.30) 1.99 (0.29)* 1.76 (0.27) á acid glycoprotein (mg/dl) 79.1 (19.4) 77.3 (19.5) 65.4 (12.9)* Athletes, particularly those at the elite level, are 2 often subjected to multiple blood tests each Values are means (SD). year. Most of the tests are for screening *p<0.05 v resting (two tailed Student’s t test). ESR, Erythrocyte sedimentation rate. purposes, and there appears to be an almost obsessional interest in iron related variables. Table 5 Iron related variables and creatine kinase activity in women soccer players The correct interpretation of these tests is therefore important, and the eVects of exercise Variable Resting Moderate training Heavy training on serum levels of various variables need to be Iron (mmol/l) 25.6 (9.5) 14.9 (6.6)* 16.3 (6.5)* taken into account. Indeed a recent paper13 Ferritin (ng/ml) 54.2 (27.8) 52.5 (22.5) 59.3 (37.0) Transferrin (g/l) 3.16 (0.37) 2.97 (0.38) 3.27 (0.41) suggested that serum ferritin may not be an Transferrin satn (%) 36 (13) 22 (9)* 21 (7)* appropriate indicator of iron status in women Creatine kinase (U/l) 151 (189) 315 (166) 194 (71) training for judo. In support of this suggestion, Values are means (SD). the authors use evidence from studies of *p<0.05 v resting (two tailed Student’s t test). endurance running that the presence of an

www.bjsportmed.com 172 Fallon, Fallon, Boston

acute phase response aVects serum ferritin lev- than 30 µg/l and 49% recommend supplemen- Br J Sports Med: first published as 10.1136/bjsm.35.3.170 on 1 June 2001. Downloaded from els. However, they do not provide any evidence tation for female athletes at ferritin levels that this response occurs during the activity greater than 26 µg/l. They suggest that a large that is the subject of their paper (judo) or dur- number of clinics begin supplementation at ing activities of a similar nature. low levels of ferritin (25 µg/l). These authors Although no data are available on the occur- recommend supplementation when the level is rence of an acute phase response after training less than 35 µg/l with continuation to a target in court and field sports, a number of authors value of 60 µg/l. have shown aspects of the acute phase response On the other hand, another recent review16 in endurance exercise. Weight et al6 showed indicated that, under normal training condi- increases in white cell count and C reactive tions, if the ferritin level is above 20–30 ng/ml protein immediately after a marathon. At 24 and the transferrin saturation above 16% iron, hours after the event, haptoglobin was signifi- supplements are not necessary. cantly increased, as was fibrinogen. In response In view of the large amount of high quality to running 25 km a day for four days, Dufaux data available on indicators of iron deficiency et al7 found an increase in C reactive protein on in the general population and the relative pau- days 3 and 5 but no change in C3 and C4. city of such data in the athletic population, Immediately after a 100 km run, Poortmans particularly that verified by bone marrow and Haralambie8 found increased albumin, biopsy or measurement of serum transferrin receptor, it would be useful if data from general transferrin, and á1 glycoprotein and decreased haptoglobin, and on the following day a medicine could be applied to athletes and used persistent decrease in haptoglobin and in- for decisions about supplementation. Although other factors may need to be considered, this creases in á1 glycoprotein and á1 antitrypsin. 9 would be facilitated if the presence of an acute Taylor et al assessed the response to a 160 km phase reaction to various types of athletic triathlon. Immediately after and 30 minutes training could be confirmed or excluded. As an after the event, an increase was found in white example, in a group of anaemic patients, Mast cell count, and serum iron and transferrin were 17 showed that, for iron storage deficiency, a decreased. At 24 hours after the run, C reactive et al serum ferritin of 30 µg/l had a sensitivity of protein was raised. In a study based on iron 92%, specificity of 98%, and a positive predic- related variables in which runners covered 50 tive value of 92%. Although a serum ferritin km a day for 20 days, no change was found in level of 12 µg/l is a highly specific indicator of serum iron, percentage transferrin saturation, iron deficiency,18 in this study this level ferritin, and transferrin at the end of the combined a high specificity (98%) with low event.11 10 sensitivity (25%) and moderate positive predic- Dickson et al found a significant increase in tive value (75%). After analysis of a subgroup serum ferritin and no change in haptoglobin 48 of otherwise healthy young women from this hours after a 160 km run. They indicated that study, the authors indicated that serum ferritin athletes who train hard every day may have should be considered the test of choice for http://bjsm.bmj.com/ falsely high serum ferritin levels, which may not assessing the need for iron treatment in this correctly reflect iron stores. They recom- group and indicated that a level of 30 µg/l was mended that, in long distance runners, ferritin an appropriate cut oV point. A serum ferritin measurements be made only after at least 14 concentration of 30 µg/l thus appears to be a days of rest. As athletes are unlikely ever to take reasonable indicator of iron deficiency and such a long rest period, they suggested that could be used as such in the female athletic serum ferritin levels about 35% above those population, particularly if an acute phase

normally taken to indicate iron deficiency be response could be shown to be absent. on September 28, 2021 by guest. Protected copyright. considered to be highly suspicious of iron defi- To facilitate this process, the present study ciency in actively training runners. In general specifically investigates the presence of an internal medicine, the diYculty of interpreting acute phase response in court and field sports. ferritin values in the presence of an acute phase In the female soccer players, 12 acute phase response has led to recommendations of reactants were measured during training peri- threshold ferritin values of between 45 and 100 ods on two occasions. Responses consistent µg/l for the diagnosis of iron deficiency in the with an acute phase response were found in five presence of chronic disease.14 of 24 tests. Serum iron and percentage The recommendation of Dickson et al10 and transferrin saturation decreased after both the desire to minimise errors in the diagnosis of heavy and moderate training weeks, and á1 deficient iron stores in athletes may have influ- antitrypsin increased after the moderate inten- enced the supplementation practices of doc- sity week. Responses that may be interpreted as tors, coaches, and athletes over the last two being in the opposite direction from an acute decades. Anecdotal reports indicate that rec- phase response were also found in the soccer ommendations for iron supplementation at group. In the moderate intensity week, the ferritin levels >50 µg/l were commonplace in white cell count decreased, and, after the heavy the 1980s. training week, white cell count, neutrophil The optimum level of ferritin below which count, platelet count, C reactive protein,

iron supplementation is recommended for ath- caeruloplasmin, and á2 acid glycoprotein all letes is unclear. Nielsen and Nachtigall15 decreased. indicate that 42% of 26 sport centres surveyed In the female netball players, 12 acute phase in Germany recommend supplementation for reactants were measured during training peri- male athletes at serum ferritin levels greater ods on two occasions. Responses consistent

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with an acute phase response were found in with a 1600 kilometre ultramarathon. Br J Sports Med. Br J Sports Med: first published as 10.1136/bjsm.35.3.170 on 1 June 2001. Downloaded from 1999;33:27–32. three of 24 tests. Serum caeruloplasmin and á1 3 Kushner I. The phenomenon of the acute phase response. antitrypsin had increased significantly after the AnnNYAcadSci1982:389:39–48. moderate training week and á acid glycopro- 4 Konijn AM. Iron metabolism in inflammation. Bailliere’s 2 Clin Rheumatol 1994;8:829–49. tein had increased significantly after the high 5 Baynes R, Bezwoda W, Bothwell T, et al. The non-immune intensity week. Responses that may be inter- inflammatory response: serial changes in plasma iron, iron binding capacity, lactoferrin, ferritin and C-reactive preted as being in the opposite direction from protein. Scand J Clin Lab Invest 1986;46:695–704. an acute phase response also occurred in the 6 Weight LW, Alexander D, Jacobs P. Strenuous exercise: netball group. In the moderate intensity week, analogous to the acute phase response? Clin Sci 1991;81: 677–83. ESR decreased, and ESR fell after the heavy 7 Dufaux B, HoVken K, Hollman W. Acute phase proteins training week. and immune complexes during several days of severe physical exercise. In: Knuttgen, HG, ed. Biochemistry of Of particular interest is the response of C exercise. International series on sport sciences, vol 13. reactive protein, a highly sensitive acute phase Champaign: Human Kinetics, 1983:356–62. reactant, which may increase by a factor of 8 Poortmans JR , Haralambie G. Biochemical changes in a 19 100 km run: proteins in serum and urine. Eur J Appl Physiol 100–1000 during the acute phase response. 1979;40:245–54. There was no change in this variable during 9 Taylor C, Rogers G, Goodman C, et al. Hematologic, iron- related, and acute-phase protein responses to sustained each of the periods of netball training and in strenuous exercise. J Appl Physiol 1987;62:464–9. the heavy period of soccer training. The C 10 Dickson DN, Wilkinson RL, Noakes TD. EVects of ultra-marathon training and racing on haematologic reactive protein levels declined during the parameters and serum ferritin levels in well trained moderate soccer training period. A similar athletes. Int J Sports Med 1982;3:111–17. reduction has recently been shown after nine 11 Seiler D, Nagel D, Franz H, et al.EVects of long distance 20 running on iron metabolism and haematological param- months of endurance running training, and it eters. Int J Sports Med 1989;19:357–62. has been suggested that this is the consequence 12 Strachan AF, Noakes TD, Kotzenberg G, et al. C reactive protein concentrations during long distance running. BMJ of a systemic anti-inflammatory eVect of 1984;29:1249–51. intense regular exercise. 13 Malczewska J, Blach W, Stupnicki R. The eVects of physical On balance, the data indicate that an acute exercise on the concentrations of ferritin and transferrin receptor in plasma in female judoists. Int J Sports Med phase response is not a consequence of training 2000;21:175–9. at levels typical of elite women’s netball and 14 Witte DL. Can serum ferritin be eVectively interpreted in the presence of the acute phase response? Clin Chem 1991; soccer squads. Therefore serum concentrations 37:484–5. of a range of biochemical variables, most 15 Neilsen P, Nachtigall D. Iron supplementation in athletes. importantly those related to iron metabolism, Current recommendations. Sports Med 1998;26:207–16. 16 Chatard J, Mujika I, Guy C, et al. Anaemia and iron can be interpreted in these groups, and perhaps deficiency in athletes. Practical recommendations for treat- others involved in similar levels and forms of ment. Sports Med 1999;27:229–40. 17 Mast AE, Blinder MA, Gronowski AM, et al. Clinical utility training, in the same way as those in the general of the soluble transferrin receptor and comparison with population. This also indicates the potential for serum ferritin in several populations. Clin Chem 1998;44: using research findings from complex and 45–51. 18 Ali MAM, Luxton AW, Walker WHC. Serum ferritin invasive studies of non-athletic populations for concentration and bone marrow iron stores: a prospective investigating athletes in court and field sports. study. Can Med Assoc J 1978;118:945–6.

19 Jupe D. The acute phase response and laboratory testing. http://bjsm.bmj.com/ Aust Fam Physician 1996;25:324–9. 1 Kushner I , Rzewnicki DL. The acute phase response: gen- 20 Mattusch F, Dufaux B, Heine O, et al. Reduction of the eral aspects. Bailliere’s Clin Rheumatol 1994;8:513–30. plasma concentration of C-reactive protein following nine 2 Fallon KE, Sivyer G, Sivyer K, et al. Changes in months of endurance training. Int J Sports Med 2000;21: haematological parameters and iron metabolism associated 21–4.

Take home message In female netball and soccer players, interpretation of haematological and biochemical vari- on September 28, 2021 by guest. Protected copyright. ables that may be components of the acute phase response need not take this response into account. As this study was of elite athletes training at relatively high levels, this guideline can probably be applied to the large number of athletes training in these sports at lower levels. It is reasonable to conclude that it also applies to male and female athletes involved in other court and field sports, but this requires confirmation.

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